Necrotizing Pneumonia Associated with Septicemia Caused by Clostridium perfringens: A Case Report

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1 內科學誌 0::87-9 Necrotizing Pneumonia Associated with Septicemia Caused by Clostridium perfringens: A Case Report Chang-Hua Chen, Shang-Yun Ho, and Kai-Huang Lin Division of Infectious Diseases, Department of Internal Medicine; Department of Radiology; Division of Critical Care Medicine, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan Abstract Clostridium perfringens (C. perfringenes) usually infects patients with trauma and malignancy, and may cause severe infections. We report a case of necrotizing pneumonia complicated with septic shock due to C. perfringenes in a 65-year-old immunocompetent male without preceding trauma or malignancy. He presented febrile, shock and respiratory distress initially. He recovered after treatment with effective antibiotics and supportive care. Our patient who developed bacteremic pneumonia complicated with septic shock illustrates the pathogenic potential of C. perfringenes in an immunocompetent host. C. perfringenes related necrotizing pneumonia related with a 50 % mortality rate was demonstrated. Infections caused by C. perfringenes are associated with high risk of mortality and morbidity if antibiotic therapy is not timely prescribed. (J Intern Med Taiwan 0; : 87-9) Key words: Necrotizing pneumonia, Septicemia, Clostridium perfringens, Immunocompetent Introduction Clostridium perfringens (C. perfringens) used to infect patients with trauma or immunocompromising conditions, such as cancer. Infections caused by C. perfringens is associated with high risk of mortality and morbidity if antibiotic therapy is not timely instituted,. Pneumonia related to C. perfringens has rarely been described, and, in most of the reported cases, clostridial pneumonia is associated with invasive procedures or penetrating chest injuries. Herein, we presented a case of necrotizing pneumonia in a 65-year-old immunocompetent male who developed septicemia due to C. Reprint requests and correspondence:dr. Chang-Hua Chen Address:Division of Infectious Diseases, Department of Internal Medicine, Changhua Christian Hospital, 5 Nanhsiau Street, Changhua 500, Taiwan

2 88 C. H. Chen, S. Y. Ho, and K. H. Lin perfringens. Case Report A 65-year-old male, previously healthy, developed productive cough 0 days before the admission. Fever was also present in the following days. He presented with chest pain, and shortness of breath. He was brought to the emergency room of Changhua Christian Hospital. There was no history of malignancy, receipt of invasive procedures, or trauma. Upon admission, he was febrile with a temperature of 8.5 C, blood pressure 80/56 mmhg, and respiratory rate 4 breaths per minute. Oxygen saturation of fingertip artery was 9% while he was breathing with room air. Laboratory examination on admission revealed white blood cell count of,400/mm, hematocrit 7.9%, platelet count,600/mm, and C-reactive protein 6.4 mg/dl (<0. mg/dl). A chest X-ray obtained on admission showed a pneumonic patch of the right middle lobe, bilateral interstitial infiltration, and pleural effusion (Figure A). Treatment was initially started with penicillin and gentamicin after blood and sputum cultures were performed. On the st hospital day, the patient's condition deteriorated rapidly. The arterial blood gas data revealed ph 7.465, PCO 9.6 mmhg, PO, 89. mmhg, HCO,.5 mmol/ L while he was breathing oxygen at L/minute per nasal cannula. The follow-up chest film showed rapid consolidation over the right lung. Antibiotics were changed to ceftriaxone (000 mg intravenously every hours) plus clarithromycin (500 mg p.o. twice daily). The chest computed tomography (CT) disclosed the massive consolidation over the right middle lung and left lung (Figure B). The bacterium was identified as C. perfringens with the use of an API 0A strip (BioMérieux, Durham, N.C.). Despite treatment of ceftriaxone and clarithromycin, he remained febrile on day 5 of hospitalization. On the 6 th hospital day, ceftriaxone was changed to amoxicillin-clavulanate intravenous 500mg every 6 hours for better coverage of the anaerobes. He became afebrile and follow-up chest radiography revealed gradual resolution of the consolidation. He recovered well and was discharged on the th hospital day. During the Figure A: A chest X-ray on admission showed a pneumonic patch of the right middle lobe, bilateral interstitial infiltration, and pleural effusion. Figure B: The chest computed tomography (CT) disclosed the massive consolidation over the right middle lung.

3 Necrotizing Pneumonia Associated with Septicemia Caused by Clostridium perfringens 89 Table. Evidence-based Literature Review for the Pleuro-pulmonary Infections with Clostridium perfringens Patient numbers Age Sex Underlying diseases Risk factors Site of infection Treatment Outcome Reference 65 M No No Necrotizing pneumonia with pleural effusion, shock Amoxiciliin/clavulanate Survive This case 8 F Paroxysmal atrial fibrillation s/p dual chamber pace-maker, hypertension, normochromic normocytic anemia, arthritis, osteoporosis, cholelithiasis NM Bilateral pleural effusion with consolidation of lower lobes and lingual, followed by gangrenous pneumonia Clindamicin and amoxiciliin/clavulanate Survive 7 59 M Carcinoma of the pancreas Hepaticojejunostomy, duodenojejunostomy A fulminant sepsis accompanied by massive intravascular haemolysis Fatal 8 NM NM NM NM Necrotizing pneumonia with pulmonary emboli NM 9 NM NM Renal transplant Renal transplant Acute empyema with hydropneumothorax, associated with bacteremia NM 0 NM NM No trauma Bowel obstruction, Bacteraemia, pneumonia associated with pleural effusion Fatal 66 M NM NM Necrotising pneumonia and empyema, complicating pulmonary embolus. Benzylpenicillin with metronidazole and drainage Fatal 5 NM NM No penetration of the thorax NM All with pleural empyema, two of five with pyopneumothorax NM 9 F NM NM Pneumonia associated with pleural empyema Penicillin and drainage Survive 4 NM NM NM NM Primary clostridial pleuropulmonary infection One with penicillin; the other uncertained One cured, the other died 5 NM NM NM An invasive procedure in 7 patients Rapidly progressive, necrotizing pneumonia and empyema NM 6 Notes : NM meant "no mention in the article".

4 90 C. H. Chen, S. Y. Ho, and K. H. Lin follow-up as an outpatient for more than one year, there were no evidence of malignancy identified, especially at respiratory tract and gastrointestinal tract. Conclusion This is a rare case of necrotizing pneumonia and septic shock caused by C. perfringens although microbial anaerobic infections were reported as early as In Jackson's study for populationbased laboratory surveillance for invasive C. perfringens disease, the annual incidence of invasive C. perfringens disease was estimated 0.8 per 00, Risk factors for C. perfringens pneumonia included aspiration of oropharyngeal or gastric contents, pulmonary embolism with infarction (hematogenous seeding of infarcted lung tissue) 5. C. perfringens pneumonia is often associated with chronic diseases, such as diabetes or cirrhosis, and underlying pleuropulmonary pathology (pulmonary tuberculosis, chronic pleural effusions) 5. Predisposing factors to C. perfringens pneumonia included malignant neoplasm, hematologic disorders, organs transplantation, recent gastrointestinal or obstetric and gynecologic surgery, intestinal obstruction, diabetes mellitus, post-splenectomy, use of cytotoxic agents or corticosteroids, and use of prophylactic agents for bowel preparation prior to surgery 5,6. After survey of this patient during the hospital stay and subsequent follow-up, there was no evidence of malignancy, especially at respiratory tract and gastrointestinal tract. We supposed that the source of C. perfringens bactermeia should come from his respiratory tract. Our patient who developed bacteremic pneumonia complicated with septic shock illustrates the pathogenic potential of C. perfringens in an immunocompetent host. After reviewing the literature on C. perfringens pleuro-pulmonary infections (Table) 7-6, we are able to identify 6 cases. The clinical presentations usually consist of pneumonia (sometimes, necrotizing pneumonia), and pleural effusion (sometimes, pleural empyema). Treatment should include drainage and adequate. As a whole, mortality rate is 50% (four expired in 8 patients). Infections caused by C. perfringens are associated with high risk of mortality and morbidity if antibiotic therapy is not timely prescribed. References. Centers for Disease Control and Prevention (CDC). Clostridium perfringens infection among inmates at a county jail-wisconsin, August 008. MMWR Morb Mortal Wkly Rep 009; 58: Chen YM, Lee HC, Chang CM, et al. Clostridial bacteremia: emphasis on the poor prognosis in cirrhosis patients. J Microbiol Immunol Infection 00; 4: -8.. Leal J, Gregson DB, Ross T, et al. Epidemiology of Clostridium species bacteremia in Calgary, Canada, J Infect 008; 57: Jackson S, Gregson DB, McFadden S, et al. Clostridium perfringens pleuropulmonary infection and septic shock: case report and population-based laboratory surveillance study. Scand J Infect Dis 00; 5: Redondo MC, Arbo MDJ, Grindlinger J, et al. Attributable mortality of bacteremia associated with the Bacteroides fragilis group. Clin Infect Dis 995, 0: Rechner PM, Agger WA, Mruz K, et al. Clinical features of clostridial bacteremia: a review from a rural area. Clin Infet Dis 00; : Palmacci C, Antocicco M, Bonomo L, et al. Necrotizing pneumonia and sepsis due to Clostridium perfringens: a case report. Cases J 009; 4; : Leeda M,van der Sloot JA. Ned Tijdschr Geneeskd 006; 50: Cannon JW. Necrotizing clostridial pneumonia: a case report and review of the literature.mil Med 00; 67: Corbett CE,Wall BM, Cohen M. Case report: empyema with hydropneumothorax and bacteremia caused by Clostridium sporogenes. Am J Med Sci 996; : Patel SB, Mahler R. Clostridial pleuropulmonary infections: case report and review of the literature. J Infect 990; : Bashir Y,Benson MK. Necrotising pneumonia and empyema due to Clostridium perfringens complicating pulmonary embolus. Thorax 990; 45: 7-.. Raff MJ, Johnson JD, Nagar D, et al. Spontaneous clostridial empyema and pyopneumothorax. Rev Infect Dis 984; 6: Kwan WC, Lam SC, Chow AW, et al. Empyema caused

5 Necrotizing Pneumonia Associated with Septicemia Caused by Clostridium perfringens 9 by Clostridium perfringens.can Med Assoc J 98; 8: Spagnuolo PJ, Payne VD. Clostridial pleuropulmonary infection. Chest 980; 78: Bayer AS, Nelson SC, Galpin JE, et al. Necrotizing pneumonia and empyema due to Clostridium perfringens. Report of a case and review of the literature. Am J Med 975; 59: 陳昶華 何上芸 林楷煌 彰化基督教醫院 感染科 影像醫學科 重症醫學科 摘 要 產氣莢膜梭菌 (Clostridium perfringens) 通常感染惡性腫瘤或是創傷的病患, 感染後有可能導致嚴重的感染 我們報告一個病例健康 65 歲男性病患, 罹患產氣莢膜梭菌導致菌血症合併壞死性肺炎, 最初臨床表現是發熱, 休克, 與呼吸窘迫 使用有效的抗生素及即時的支持治療, 病患恢復健康 這位病患是產氣莢膜梭菌導致生菌血症與肺炎併發休克 在回顧世界文獻並且分析產氣莢膜梭菌相關性壞死性肺炎的案例進行分析, 整體而言, 產氣莢膜梭菌感染引起的死亡率為 50% 產氣莢膜梭菌感染在高風險病患, 如果沒有及時治療會發生極高的死亡率和併發症

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